Paying for Value. I’m Overwhelmed. Please Read This

As you may know from previous posts, I sit on a Center for Medicare and Medicaid Services (CMS) panel about Quality Measurement Development: Supporting Efficiency and Innovation in the Process of Developing CMS Quality Measures. Jeesh! What a mouthful! In English, for me, this means, if Medicare is going to pay for value in health services, what is value? How will value be measured? How will value measures be created? And, should we care? We (people at the center of care – patients, clinicians, and those that support us) absolutely should care. First of all, we are the ones who are actually paying. Medicare, Medicaid, and insurance companies write the checks, but their accounts are filled by us as taxpayers and employees. The more money spent on healthcare, the less money is spent on our wages, public health, safety, everything. Hospitals and professional practices respond to how they get paid more than anything. When they are paid for volume – more treatment, surgery, days, and visits – they do more since it means more money for them. We know that more does not necessarily mean better for our health. The healthcare industry is creeping toward paying for value, not volume. Value should mean better medical care, better health, better relationships within our health teams, and better work life for those of us that are professionals. The definition and the measurement of value become critical. An example is readmission rates. Volume is paying for every admission. Value is not paying for a readmission to a hospital within a certain number of days. There are roughly 1,000 of such quality or value measures.

I want to share with you some of the recommendations made by the technical expert panel so far (this is from the second of four all-day sessions). You can find the full report from the January meeting here on the CMS website, but it’s hard to get to the report, so I put it here to make it easier. I’m listing the recommendations below with my interpretation in italics of what they mean. Nobody at CMS or Battelle or the Panel has endorsed my interpretations. They’re all mine. But it’s no good if you don’t know what’s going on and I’m not sure if reading the report will help. So, here goes:

Recommendations

Institute a governance process to help plan, develop, and manage shared measure testing resources.Measures need to be tested to see if they work. Working means that they measure what we want them to measure, that they measure the same thing every time, and that it makes sense. People developing measures use large sets of data to test to see if the measures work. Many organizations suggest measures, measure the measures, and publish the measures. This recommendation says that there needs to be a governance process (a clear and understandable way to make decisions) about how measures are tested. Right now measures are mostly tested using claims and electronic medical record data. It’s not enough. Data from patients and the experience of patients and clinicians are important too. We don’t have much experience with using this kind of data for value. Lots of decisions ahead of us.

Incentivize participation in measure testing.Everyone who creates measures won’t test measures out of the goodness of their hearts or because it’s the right thing to do. Incentives encourage people to test measures in new ways. Incentives for organizations can be similar to incentives for people. I am more likely to do something if it’s easier than not doing it; if it’s required with a penalty if I don’t; if people give me credit for my work; if I get paid or a discount on something else; if I get more business if I do it. You get the idea.

Promote data element standardization and education.Measures are made up of data elements. A very simple measure is the fraction of females in a group (55% of the group are females). But it’s not so simple. How do you define the group and how do you define the data element, females? Is a female a person that can bear children, has two X chromosomes, self-identifies as female… What’s important with measures is that everyone using the measure defines it the same – there are agreed upon standards. A requirement to make the definitions and standards available for anyone to see helps too. Nothing hidden.

Implement a framework with a long-term plan on how CMS will approach measurement.Changes to the way measures are developed won’t happen by waving a magic wand. It takes time and effort by lots of people. Some things tried, won’t work. Something else will need to be tried. It takes a long-term plan, like retirement. We need a picture of how the plan will move along and adapt to new knowledge. That’s the framework.

Institute an acceptable “quick path to failure” mechanism in the measure development process with well-defined steps.Developing measures is expensive and time-consuming. Whenever new things are tried, some don’t work. We don’t learn to walk without falling. We need to know that something isn’t going to work as soon as possible so we can try something else. But if people are going to “fail early” they need to know how to do that and be paid for the work they do, even if it doesn’t turn out as expected. Again, incentives.

To facilitate development of cross-program measures, consider a different organizing structure for measure development contracts/projects that cuts across programs. Right now, most measures are diagnosis-specific for one setting (home, hospital, nursing home). But people aren’t their diagnosis and they spend time in many settings. Measures across diagnoses and settings are hard to develop. The science is young. They’re different and should be managed differently. As a patient, I care about this a lot.

Provide funding for the development and implementation of a national testing collaborative.Changing how we develop measures is expensive and a risk. The government should pay for some of this experimenting with testing. It’s an incentive.

Develop an objective scoring system to evaluate measure testing concepts that are currently assessed subjectively such as importance, burden, and feasibility.Changing how measures are tested could end up like the Wild West- shooting from the hip, pretty wild, with those having big guns controlling the town. Having a scoring system (more points for helping patients and clinicians, more points if it’s easy to do it in many places, more points if I can do it the same way after you figure it out) really helps manage these new ways of testing measures.

Overwhelmed? No wonder. Me, too. I’m sitting at this table because I think it’s important stuff. I appreciate that CMS cares and included me. I respect the knowledge and passion of those around the table and they respect me. It’s government at its best. It helps when you understand this too. Even a little bit. Please ask questions, comment, and share. We’re pretty smart but not as smart as we think. We need your smarts.

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About Danny van Leeuwen

3 Comments

What a complicated task with far-reaching affects. One thought I have is about electronic health records. Several years ago when I became eligible for Medicare benefits due to disability, I discovered a glaring oversight in Medicare regulations. My doctor who reviewed my sleep apnea test, signed his report electronically. Medicare would not accept his signature this way. It had to be hand written. My doctor refused to sign the report. I could not get coverage for my C-PAP supplies without his signature. There only solution was for me to take another sleep apnea study with a different doctor. This made no sense to me. Since then I’ve been paying for my supplies out of my own pocket. The point I want to make is that Medicare appears to be unable to adjust to changes in the healthcare field. Setting up quality measures for competent healthcare is a great goal, but how can this happen if they trip over things like accepting electronic medical records as valid?

I’m so grateful you’re doing this difficult work, Danny…I know it’s dry and requires skill with a language for terms most of us(certainly not me) don’t use in daily life, but as I keep saying to myself with all the community work I do, “the devil’s in the details,” so patient perserverence is always required to keep working and studying. And what I hope results is a macro-change so it becomes common knowledge and automatic assumption that patient-centered measures for quality care are the norm.

Hi Danny, Thanks for serving on this TEP and I have some experience with quality measures, so here is my question. Can CMS make the measures more patient-centered? I see a lot of process quality measures and few outcome measures but that is what I care about. For example, I hear there are quality measures about patients with high cholesterol taking a statin. What if the patient doesn’t want to take a statin and controls the cholesterol using another treatment or lifestyle option? Isn’t that the outcome desired? But if there was a process measure about percentage of patients with high cholesterol taking a statin, the doctor would not get to count the patient who chose another treatment but achieved the desired outcome: cholesterol under 200. I know process quality measures are easier but there needs to be a really good reason to measure and report them. Physicians’ burdens are too high for collecting and reporting quality data. Sometimes a doctor and I don’t agree on the problem, diagnosis, or treatment. Is there a quality measure on patients’ agreement with the diagnosis? Chances are if I don’t agree with the diagnosis, I am not going to fill the prescription and take it as prescribed. Yes, I know that’s a process measure but it is more patient-centered than did the physician prescribe x for y. I know it is really difficult to create and test valid and reliable quality measures, but I wish that we could pay for the correct and efficient diagnosis, effective treatment, and not pay for incorrect diagnosis, and unnecessary or ineffective treatments. If the most common outcome patients want is: happy healthy days at home, then can we find quality measures directly tied to that outcome?